Management of hospitalised adults with coronavirus disease 2019 (COVID-19): a European Respiratory Society living guideline

Abstract

IntroductionHospitalised patients with coronavirus disease 19 (COVID-19) as a result of SARS-CoV-2 infection have a high mortality rate and frequently require non-invasive respiratory support or invasive ventilation. Optimising and standardising management through evidence-based guidelines may improve quality of care and therefore patient outcomes.MethodsA task force from the European Respiratory Society and endorsed by the Chinese Thoracic Society identified priority interventions (pharmacological and non-pharmacological) for the initial version of this “living guideline” using the PICO (population, intervention, comparator, outcome) format. The GRADE approach was used for assessing the quality of evidence and strength of recommendations. Systematic literature reviews were performed, and data pooled by meta-analysis where possible. Evidence tables were presented and evidence to decision frameworks were used to formulate recommendations.ResultsBased on the available evidence at the time of guideline development (February 20th, 2021) the panel makes a strong recommendation in favour of the use of systemic corticosteroids in patients requiring supplementary oxygen or ventilatory support, and for the use of anticoagulation in hospitalised patients. The panel makes a conditional recommendation for IL-6 receptor antagonist monoclonal antibody treatment and high flow nasal oxygen or continuous positive airway pressure in patients with hypoxaemic respiratory failure. The panel make strong recommendations against the use of hydroxychloroquine and lopinavir-ritonavir. Conditional recommendations are made against the use of azithromycin, hydroxychloroquine and azithromycin, colchicine, and remdesivir, in the latter case specifically in patients requiring invasive mechanical ventilation. No recommendation was made for remdesivir in patients requiring supplemental oxygen. Further recommendations for research are made.ConclusionThe evidence base for management of COVID-19 now supports strong recommendations in favour and against specific interventions. These guidelines will be regularly updated as further evidence becomes available.

Azithromycin and hydroxychloroquine in hospitalised patients with confirmed COVID-19: a randomised double-blinded placebo-controlled trial

“…The combination of azithromycin and hydroxychloroquine did not increase the likelihood of survival or discharge from hospital of patients with COVID-19. This conclusion is consistent with recent European Respiratory Society COVID-19 guidelines [ 35 ], which reported no clinical benefits associated with using hydroxychloroquine and/or azithromycin to treat patients hospitalised with COVID-19 (in the absence of bacterial infection).…”

Prevalence of pulmonary embolism in patients with COVID-19 at the time of hospital admission and role for pre-test probability scores and home treatment

“…There was no significant difference between the groups with or without acute PE at the time of hospital admission for COVID, in terms of VTE risk factors and YEARS items ≥1 ( table 1 ). Last, we confirm that no patient received COVID-19 therapy such as corticosteroid of anticoagulation prior to hospitalisation [ 1 , 3 ].…”

Antiviral treatment selection for SARS-CoV-2 pneumonia

“…Besides antiviral agents and neutralizing monoclonal antibodies, the therapeutic approach to moderate/severe COVID-19 also involves the administration of immunomodulatory and antithrombotic agents. More details on treatments other than antiviral agents are available in currently released guidelines [ 18 , 69 ] …”

“…Overall, we truly welcome this new complex scenario, in which classical antiviral agents, neutralizing monoclonal antibodies, and anti-inflammatory or immunomodulatory agents are carving out their place in therapeutic algorithms based on RCT results (i.e., on high-level evidence) [ 69 ]. We should continue on this path.…”